Microsoft word - cms step therapy_v2_10 26 12.docx
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: ALENDRONATE SODIUM Step 2: ACTONEL, ATELVIA
Previous trial on at least ONE of the following: Atacand, Atacand HCT, Step 1: ATACAND, ATACAND HCT, BENAZEPRIL HCL, BENAZEPRIL-
HYDROCHLOROTHIAZIDE, BENICAR, BENICAR HCT, CAPTOPRIL,
CAPTOPRIL-HYDROCHLOROTHIAZIDE, DIOVAN, DIOVAN HCT, EDARBI,
EDARBYCLOR, ENALAPRIL MALEATE, ENALAPRIL-
HYDROCHLOROTHIAZIDE, EPROSARTAN MESYLATE, FOSINOPRIL
SODIUM, FOSINOPRIL-HYDROCHLOROTHIAZIDE, IRBESARTAN,
IRBESARTAN-HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-
HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN-
HCTZ, lisinopril, lisinopril-HCTZ, HYDROCHLOROTHIAZIDE, MICARDIS, MICARDIS HCT, QUINAPRIL HCL,
losartan, losartan-HCTZ, Micardis, QUINAPRIL-HYDROCHLOROTHIAZIDE, RAMIPRIL, TEVETEN, TEVETEN
Micardis HCT, quinapril, quinapril- HCT Step 2: AMTURNIDE, VALTURNA
HCTZ, ramipril, Teveten, Teveten HCT Previous trial on at least ONE of the Step 1: ABILIFY, ABILIFY DISCMELT, CLOZAPINE, OLANZAPINE,
OLANZAPINE ODT, QUETIAPINE FUMARATE, RISPERIDONE, RISPERIDONE
ODT, SYMBYAX, ZIPRASIDONE HCL Step 2: FANAPT, INVEGA, LATUDA,
quetiapine, risperidone, risperidone SAPHRIS
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: buprenorphine
Step 1: BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, KADIAN,
LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE
SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL
methadone, morphine ER, Nucynta Step 2: AVINZA ER, Opana ER, OxycontinPrevious trial on BOTH of the
Step 1: ACTONEL, ALENDRONATE SODIUM Step 2: IBANDRONATE SODIUM
Actonel Previous trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, EXALGO, FENTANYL, KADIAN,
LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE
SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL
levorphanol, methadone, morphine Step 2: BUTRANS
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: atorvastatin, lovastatin, Step 1: AMLODIPINE BESYLATE, ATORVASTATIN CALCIUM, LOVASTATIN,
PRAVASTATIN SODIUM, SIMVASTATIN Step 2: CADUET
Step 1: DICLOFENAC POTASSIUM, DICLOFENAC SODIUM, IBUPROFEN,
MELOXICAM, NABUMETONE, NAPROXEN, NAPROXEN SODIUM,
Previous trial on at least ONE of the Step 1: BUPROPION HCL, BUPROPION HCL SR, CITALOPRAM HBR, following: bupropion, citalopram, FLUOXETINE DR, FLUOXETINE HCL, FLUVOXAMINE MALEATE,
MAPROTILINE HCL, MIRTAZAPINE, PAROXETINE HCL, SERTRALINE HCL,
VENLAFAXINE HCL, VENLAFAXINE HCL ER Step 2: APLENZIN,
CYMBALTA, EMSAM, LUVOX CR, PEXEVA, PRISTIQ ER, VIIBRYD
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the Step 1: BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, following: hydrocortisone,
CLOBETASOL EMOLLIENT, CLOBETASOL PROPIONATE,
HYDROCORTISONE, HYDROCORTISONE VALERATE, TRIAMCINOLONE
Previous trial on at least ONE of the Step 1: LANSOPRAZOLE, OMEPRAZOLE, OMEPRAZOLE-SODIUM
BICARBONATE, PANTOPRAZOLE SODIUM, PREVACID Step 2: DEXILANT
Step 1: LANTUS, LANTUS SOLOSTAR, LEVEMIR, NOVOLIN 70-30, NOVOLIN
N, NOVOLIN R, NOVOLOG, NOVOLOG MIX 70-30 Step 2: SYMLINPEN 120, SYMLINPEN 60
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: SPIRONOLACTONE, SPIRONOLACTONE-HCTZ Step 2: EPLERENONE
spironolactone-HCTZPrevious trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, FENTANYL, KADIAN,
LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE
SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL
levorphanol, methadone, morphine Step 2: EXALGO
ER, Nucynta ER, Opana ER, Oxycontin Previous trial on generic gabapentin
Step 1: GABAPENTIN Step 2: GRALISE, HORIZANT
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: Actoplus Met/XR,
Step 1: ACTOPLUS MET, ACTOPLUS MET XR, ACTOS, DUETACT,
GLIMEPIRIDE, GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE-METFORMIN,
GLUMETZA, GLYBURIDE, GLYBURIDE MICRONIZED, GLYBURIDE-
METFORMIN HCL, JANUMET, JANUMET XR, JUVISYNC, KOMBIGLYZE XR,
glyburide-metformin, Janumet/XR, METFORMIN HCL, METFORMIN HCL ER, PRANDIMET, TOLAZAMIDE,
TOLBUTAMIDE Step 2: BYDUREON, BYETTA, VICTOZA 3-PAK
metformin/ER, Prandimet, tolazamide, tolbutamidePrevious trial on at least ONE of the following: lovastatin, pravastatin, simvastatin, Vytorin, atorvastatin
Step 1: ATORVASTATIN CALCIUM, LOVASTATIN, PRAVASTATIN SODIUM,
OR previous trial on at least ONE SIMVASTATIN, VYTORIN, VYTORIN Step 2: JUVISYNC of the following: Metformin, Januvia Previous trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL,
LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE
SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL
levorphanol, methadone, morphine Step 2: KADIAN
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: ATORVASTATIN CALCIUM, CRESTOR, CRESTOR, FLUVASTATIN
SODIUM, LESCOL, LESCOL XL, LOVASTATIN, PRAVASTATIN SODIUM,
Crestor, atorvastatinPrevious trial on at least ONE of the Step 1: ZALEPLON, ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER Step 2:
Previous trial on at least TWO of the following: methocarbamol,
Step 1: BACLOFEN, CHLORZOXAZONE, CYCLOBENZAPRINE HCL,
DANTROLENE SODIUM, METHOCARBAMOL, ORPHENADRINE CITRATE,
MUSCLE RELAXANT cyclobenzaprine, dantrolene,
ORPHENADRINE COMPOUND, SKELAXIN, TIZANIDINE HCL Step 2:
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL,
KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE,
Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: NUCYNTA ER ER, Opana ER, Oxycontin
Previous trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL,
KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE,
Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, NUCYNTA ER, OXYCONTIN Step 2: OPANA ER, levorphanol, methadone, morphine OXYMORPHONE HCL ER, Nucynta ER, Oxycontin
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: Avinza,
Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL,
KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE,
Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: OXYCONTIN ER, Nucynta ER, Opana ERPrevious trial on at least TWO of
Step 1: DEXILANT, LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE
SODIUM, PREVACID Step 2: NEXIUM, OMEPRAZOLE-SODIUM
Dexilant Previous trial on at least ONE of the Step 1: AMLODIPINE BESYLATE, ATENOLOL, DILTIAZEM 24HR ER, following: amlodipine, diltiazem,
DILTIAZEM ER, DILTIAZEM HCL, ISOSORBIDE DINITRATE, ISOSORBIDE
MONONITRATE, ISOSORBIDE MONONITRATE ER, METOPROLOL
SUCCINATE, METOPROLOL TARTRATE, PROPRANOLOL HCL, VERAPAMIL
ER, VERAPAMIL ER PM, VERAPAMIL HCL Step 2: RANEXA
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: hydrocodone/APAP, Step 1: ACETAMINOPHEN-CODEINE, BUTALB-CAFF-ACETAMINOPH-butalbital/APAP/caf/cod,
CODEIN, CODEINE SULFATE, HYDROCODONE BIT-IBUPROFEN,
HYDROCODONE-ACETAMINOPHEN, HYDROMORPHONE HCL, MORPHINE
SULFATE, OXYCODONE CONCENTRATE, OXYCODONE HCL, OXYCODONE
hydrocodone/IBU, hydromorphone, HCL-ACETAMINOPHEN, OXYCODONE HCL-ASPIRIN, OXYCODONE HCL-morphine IR, oxycodone,
IBUPROFEN, OXYCODONE-ACETAMINOPHEN Step 2: NUCYNTA,
oxycodone/ASA, oxycodone/IBUPrevious trial on at least ONE of the following: zolpidem, zaleplon AND Step 1: AMITRIPTYLINE HCL, AMOXAPINE, CLOMIPRAMINE HCL,
previous trial on at least ONE of the DESIPRAMINE HCL, DOXEPIN HCL, IMIPRAMINE HCL, IMIPRAMINE
PAMOATE, NORTRIPTYLINE HCL, PROTRIPTYLINE HCL, TRIMIPRAMINE
MALEATE, ZALEPLON, ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER
desipramine, doxepin, imipramine, Step 2: SILENOR
nortriptyline, protriptyline, trimipramine Previous trial on at least ONE of the following: Asmanex, Advair,
Step 1: ADVAIR DISKUS, ADVAIR HFA, ASMANEX, FLOVENT DISKUS,
albuterol, Flovent, Pulmicort, Qvar, FLOVENT HFA, FLUNISOLIDE, FLUTICASONE PROPIONATE, NASONEX,
Symbicort OR previous trial on at PROAIR HFA, PROVENTIL HFA, PULMICORT FLEXHALER, QVAR,
RHINOCORT AQUA, SYMBICORT Step 2: SINGULAIR
flunisolide, fluticasone, Nasonex, Rhinocort AQ
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Steps Step 1: ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER Step 2: EDLUAR,
Previous trial on at least ONE of the Step 1: ATORVASTATIN CALCIUM, LOVASTATIN, PRAVASTATIN SODIUM,
following: lovastatin, pravastatin, SIMVASTATIN Step 2: ADVICOR, CRESTOR, SIMCOR, VYTORIN
simvastatin, atorvastatinPrevious trial on at least ONE of the following: benazepril, benazepril-HCTZ, captopril, captopril-HCTZ, Step 1: ATACAND, ATACAND HCT, BENAZEPRIL HCL, BENAZEPRIL-enalapril, enalapril-HCTZ,
HYDROCHLOROTHIAZIDE, BENICAR, BENICAR HCT, CAPTOPRIL,
CAPTOPRIL-HYDROCHLOROTHIAZIDE, DIOVAN, DIOVAN HCT, EDARBI,
ENALAPRIL MALEATE, ENALAPRIL-HYDROCHLOROTHIAZIDE,
quinapril, quinapril-HCTZ, ramipril EPROSARTAN MESYLATE, FOSINOPRIL SODIUM, FOSINOPRIL-
AND previous trial on at least ONE HYDROCHLOROTHIAZIDE, IRBESARTAN, IRBESARTAN-of the following: Atacand, Atacand HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-HCT, Benicar, Benicar HCT,
HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN-
HYDROCHLOROTHIAZIDE, MICARDIS, MICARDIS HCT, QUINAPRIL HCL,
QUINAPRIL-HYDROCHLOROTHIAZIDE, RAMIPRIL, TEVETEN, TEVETEN
HCT Step 2: TEKAMLO, TEKTURNA, TEKTURNA HCT
Micardis, Micardis HCT, Teveten, Teveten HCT
SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: omeprazole,
Step 1: CELEBREX, DEXILANT, DICLOFENAC POTASSIUM, DICLOFENAC
SODIUM, IBUPROFEN, LANSOPRAZOLE, MELOXICAM, NABUMETONE,
NAPROXEN, NAPROXEN SODIUM, NEXIUM, OMEPRAZOLE, OMEPRAZOLE-
previous trial on at least ONE of the SODIUM BICARBONATE, OXAPROZIN, PANTOPRAZOLE SODIUM,
meloxicam, ibuprofen, naproxen, nabumetone, diclofenac, Celebrex
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
TEVETEN . 1,11TEVETEN HCT . 1,11TIZANIDINE HCL . 7TOLAZAMIDE . 6TOLBUTAMIDE . 6TRAZODONE HCL . 8TRIAMCINOLONE ACETONIDE. 4TRIMIPRAMINE MALEATE . 10ULORIC . 12VALTURNA . 1VENLAFAXINE HCL . 3VENLAFAXINE HCL ER . 3VERAPAMIL ER . 9VERAPAMIL ER PM . 9VERAPAMIL HCL . 9VICTOZA 3-PAK . 6VIIBRYD . 3VIMOVO . 12VYTORIN . 6,11ZALEPLON . 7,10ZEGERID . 9ZIPRASIDONE HCL . 1ZOLPIDEM TARTRATE . 7,10,11ZOLPIDEM TARTRATE ER . 7,10,11ZOLPIMIST . 11
Source: http://www.selecthealthadvantage.org/assets/pdf/step-therapy-criteria_v1.pdf
IL3 Institute for LifeLong Learning Institut de Formació Contínua Instituto de Formación Continua Universitat de Barcelona © de esta edición: Fundació IL3-UB, 2010PROCESO DE ATENCIÓN URGENTE A LA MUJERD.L.: B-36510-2010 T3B TRASTORNOS HIPERTENSIVOS DEL EMBARAZO (THE)Introducción a los trastornos hipertensivos del embarazo (THE) . 1.2. Definición y clasificación de los THE (OMS
CONFIDENTIAL REPORT AN INVESTIGATION INTO THE DEATH OF AR Fifty-seven year-old male resident of Western State Hospital, dies after being struck by an oncoming tractor-trailer while walking along Interstate 81, near WSH, in Staunton, Virginia. DRVD CASE# 96-4808M Department For Rights of Virginians With Disabilities Fishersville Field Office Beth Chadwell, Advocate April
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